Advances in Treating CLL at Any Age

Published on
April 3, 2015

Topics include:
Treatment

With many
new CLL treatments available, can a patient’s age limit the list of available
options? Drs. Alessandra Ferrajoli and Nitin
Jain, CLL experts from MD Anderson Cancer Center, explore recent progress in
treating elderly and difficult-to-treat patients, plus factors that people
should consider with their doctor when choosing a treatment.

Sponsored by the Patient Empowerment Network,
which received educational grants from AbbVie and Genentech.

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Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:

Hello. I'm Andrew
Schorr. I'm sitting with two CLL experts
from one of the leading leukemia centers, and that's MD Anderson Cancer Center
in Houston, Dr. Nitin Jain, Dr. Alessandra…

Dr. Ferrajoli:

Ferrajoli.

Andrew Schorr:

…Ferrajoli. I have to get my Italian pronunciation right—and
they've done a lot of groundbreaking work in CLL. And some of the areas that they've studied
have also been helping for older patients get the best chance at a long, high
quality of life. So let's start with
you, Alessandra. Should an older patient
feel that they get second best, that they can't get the best medicine
today?

Dr. Ferrajoli:

No, definitely not because, first of all, when we look at the
person, age is not so important as fitness and how your other organ functions
are and whether you have any important other diseases. So when we evaluate the patient, we have to
consider all those components.

So we may have an older person that is otherwise fit. They can receive what you may call a little
more aggressive treatment. But we also
may have at times a younger person for which we need to make adjustment. So I truly feel that an older person has the
same options than a younger person has.
They may need to be personalized.
They may need—the therapy may need to be modified but not to the cost of
being effective.

Andrew Schorr:

Okay. Dr. Jain, so
it used to be with some of the more aggressive types of CLL like 17p…

Dr. Jain:

Right.

Andrew Schorr:

…that you would say oh, my goodness, well, maybe you're going
to need a transplant, and that's a heavy approach. But now you're seeing with some of the
medicines, which would be appropriate for older patients, that even with 17p
you may have a pill they could take.

Dr. Jain:

Sure. I think this
concept of older patients versus young patients or, you know, fitness status, I
think was more relevant I think in the chemotherapy era. But I think in the new
concept, newer targeted therapies patients, older patients are getting equal
benefit as younger patients. These drugs
are not generally toxic. They don't affect the kidney functions, liver
functions, and the tolerability in older patients for drugs such as ibrutinib (Imbruvica)
or idelalisib (Zydelig) is thought to be equal to younger patients. So I think that bar of younger versus old is
kind of going away in the era of targeted therapy.

Now, specifically you mentioned about the 17p deletion, and I
think that's correct that if you use chemotherapy?based approaches—which we
were doing before the targeted therapies because that was the best available,
that was not the most optimal therapy.
After FCR treatment, median time that a patient stays in remission is
just around a year with 17p deletion.

But now we are seeing with ibrutinib, idelalisib and other
drugs in the pipeline that these patients are getting first remission of the
order of three, four years, perhaps longer.
So I think this says the new drugs are remarkable, and especially for
patients with deletion 17p. And I think
the issue of transplant, that's another kind of discussion about patients with
17p, but I think these drugs are making a big headway for all groups of
patients, older patients, 17p deleted patients, And I think we're going to see
gradually in younger patients also in the frontline setting.

Andrew Schorr:

Do we know how long these newer drugs will work for
someone? Because many people living, you
know, in their late 80s, maybe even 90s, living with CLL, so now you're going
to have them take a pill. What do we
know about what's come up in some other areas of cancer, resistance where the
cancer kind of outsmarts it? Do we know
yet? And if there is resistance, might
you have something new that's going to come along that they could then switch
to?

Dr. Ferrajoli:

So this is a very good question. We don't know a lot for the majority of
patients. What we know is that the
median duration of response for a patient with 17p pretreated, so we're talking
about a very—a relatively advanced patient with ibrutinib is in the order of
two years.

We don't know what the duration is for a patient that receives
it as an initial therapy or as their first salvage therapy, and that doesn't
have aggressive features. It's likely to
be much longer than two years, just based on how long we have been running
those trials. My educated guess is that
it's going to be in the order of several years.

Now, the development of resistance is a problem, but it seems
to be happening in a very, very, very small percentage of patients. So—and the mechanism that is one of two that
have been kind of identified, but not for everyone. So that is, you know, a field…

Andrew Schorr:

That's good news.

Dr. Ferrajoli:

…where we are looking at it, but it's good news. It doesn't seem to be a problem, and there is
definitely not a clock. We are not like
seeing, oh, everyone at 18 months developed resistance—no. We are not seeing of this.

It's also true that thinking about what to do if resistance
occurs or if, you know, for any reason tolerance, possible side effects—we
don't know what the side effects of some of the treatment may be in year four,
year five, year six. If for any reason
we need to change therapy, what I tell my patients is similar to what they may
tell you in a store or a restaurant. The
menu is getting longer and longer.

Andrew Schorr:

Right.

Dr. Ferrajoli:

We are having more and more agents. For example, venetoclax, that is ABT-199, is
extremely effective, so that is likely to be one of the most effective
therapies to use in this setting.

The new CD20 antibodies are also effective, and also we have to
think that maybe in the years to come people may use the targeted therapy more
as first line. They may not even be
exposed to the monoclonal antibodies.
And then, you know, we have so many other. We have older development around the cellular
therapy, the CAR T cells will likely be refined.

Andrew Schorr:

Lot to talk about.

Dr. Ferrajoli:

Lots to talk about.

Andrew Schorr:

Dr. Jain, just to sum up then, she's rattled off a long
list, a growing list of treatments. So
people use you, as a CLL specialist and researcher, as their barometer for
hope. What do you want to say to the CLL
community about how you feel about the change and how it may benefit them
generally?

Dr. Jain:

Well, I think—when I think the therapies we know right now, the
new therapies, the targeted therapies have all significantly advanced the field
for CLL patients as compared to what was with chemotherapy. Though, I mean,
there is a subgroup of patients which I think chemotherapy is still is valid
option—but for a majority of patients I think we're moving to targeted
therapies.

And I think in the years to come, in the next I think two,
three years, four years, I think we're going to see more of immune-based
therapies for patients with CLL. There
is already interesting data generated with chimeric antigen receptor therapy,
and I think in the next one or two years we're going to see clinical trials
with immune checkpoint block inhibitors, PD-1, PDL-1, which are the drugs which
are now approved in melanoma setting and some solid tumor setting.

I think we're going to see those trials coming up, and I think
that will be a very interesting combination because those are again based on
the fact that you're targeting the immune system of the CLL patients not
targeting the CLL cells. So it's a new
phenomenon which already works for patients with melanoma, solid tumors, in
some group of patients. So I think those
trials we will have to see. And those
have the potential, potentially the potential of long?term disease?free
survival, long?term remissions, possibility of a cure. But I think the next few years are going to
be crucial in that aspect.

Andrew Schorr:

So you're feeling very positive.

Dr. Jain:

Right. I mean, yeah, I
think those are the trials we are involved in at MD Anderson, the checkpoint
inhibitor trials, so we'll have to see how—they should open in the next few
months, but we'll have to see in the next one or two years how—what data we
generate from that.

Andrew Schorr:

Tremendous change going on in CLL and tremendous hope for a
broad group of patients no matter what your age is. So stay tuned and stay informed.

I'm Andrew Schorr.
Remember, knowledge can be the best medicine of all.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Dr. Valentin Goede is a hematologist/oncologist and also a gerontologist who specializes in CLL care at the University of Cologne in Germany. In this interview with Patient Power's Andrew Schorr he explains how this is a much more positive time for the elderly who have CLL.